First Name:
Last Name:
Address:
City:
State:
New Hampshire
Zipcode:
Home Phone:
Work Phone:
Cell Phone:
Where to Contact:
Select One
Home Phone
Work Phone
When to Contact:
AM
PM
Email Address:
* Please note: Without a valid email address, we will be unable to return your E-Quote!
Social Security Number:
(Optional)
Date of Birth:
mm/dd/yyyy
** What date would you like coverage to begin?
mm/dd/yyyy
** Please note: Select a date that is at least three days from current date.
General Insurance Information
Is this your primary residence?
Yes
No
Last Name:
Who is your current Insurance Carrier?
Do you currently have auto insurance?
Yes
No
(If so, this could qualify you for an additional credit.)
Number of property insurance claims in the last 5 years?
Is any business or child care conducted on your property?
Yes
No
If yes, please describe what type:
Do you own pets?
Yes
No
If yes, what kind?
Do you have a pet that has bitten anyone?
Yes
No
Information About Your Home's Location
County:
Name of Responding fire department:
Distance to fire department:
(miles, ie. 0.5, 1.0)
Distance to fire hydrant:
feet
Is your home subject to flood?
Yes
No
Information About Your Home's Construction
Construction type:
How many condomiums in your building?:
Do you have any of the following:
Smoke Detectors
Fire Extinguishers
Dead Bolt Locks
Fire Alarm Alerts Central Station
Fire Alarm Alerts Police Station
Burglary Alarm Alerts Central Station
Burglary Alarm Alerts Police Station
What is Your Primary Source for Heating Your Home?
Select One
Oil
Gas
Electric
If Other Explain:
Do you have a wood, coal or pellet stove?
Yes
No
Was the device inspected by the local Fire Department or Building Inspector?
Yes
No
Is the device/installation UL Listed and installed by a qualified contractor?
Yes
No
Are the chimney and flue pipe cleaned annually?
Yes
No
Number of Units between
fire walls?
What floor is your apartment or condominium on?
Information About Your Coverage
How much coverage do you want on your household belongings/personal property?
($15,000 min. limit, $5,000 per room)
Please select a personal liability coverage amount:
Select one
$100,000
$300,000
$500,000
Please select a medical payments coverage amount:
Select One
$1,000
$2,500
$5,000
$10,000
Please select the deductible amount:
Select One
$250
$500
$1,000
Would you like increased coverage for Credit Cards, Fund Transfer Cards, Forgery and Counterfeit Money Coverage?
Yes
No
Would you like to include Identity Fraud Expense Coverage?
Add to your renters policy for $25.00 per year.
Yes
No
Would you like to include Valuable Items coverage?
Yes
No
Information About Your Valuable Items
Please enter the corresponding numeric dollar values next to the items you are interested in insuring:
Camera
China & Crystal
Fine Arts
Firearms
Furs
Jewelry
Musical Instruments
Personal Computers
Silverware
Thank you for your information. We will email you back in 2 business days. If you have any questions we will call you directly so we can give you the most accurate quote possible. If you have any questions or concerns, please call us at 603-437-1992.